Provider Demographics
NPI:1508483843
Name:SMITH, AQUANTINA (MED, LAT)
Entity Type:Individual
Prefix:
First Name:AQUANTINA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MED, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8020 LEAD CIR APT 1012
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-8510
Mailing Address - Country:US
Mailing Address - Phone:281-636-7866
Mailing Address - Fax:
Practice Address - Street 1:8020 LEAD CIR APT 1012
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-8510
Practice Address - Country:US
Practice Address - Phone:281-636-7866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT46902255A2300X
TX174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty